Wayne_Well Abandonment_20240311 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. W e r l e y 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well constniction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
3 344-A wells abandoned:.—
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 .99 (gal.)
ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
W M 0701284 7c.Type of disinfectant used:
List all applicable arll construction permits(i.e.UIC County.State,Variance,etc.)iifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout IN Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) I]Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
EMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement "-30 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier Bentonite "' 25 Ibs
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite - gravity feed from 20 to 5 ft bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
3/1/2024 Neat Cement - pour from 5 ft bgs to surface
4.Date well(s)abandoned:
Sa.Well location: MAR
, ���A
Prop Wawa Goldsboro N/A M
Facility/Owner Namc Facility ID#(ifapplicable) 8. r Ifigation:
2853 US-70 Hwy, Goldsboro, NC 27530 JOG
s- Za
Physical Address,City,and Zip Signature ofCertificd Wclltoav or Well Owner Dater
Wayne 2671815879 By signing this,/orin, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy oJ'this record has been provided to the well owner.
(if well field,one lat'long is sufficient) 9.Site diagram or additional well details:
35.428116 N 7 8.0 644 89 W, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
� 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M V q�V-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6.25 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 7.76 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft) loc.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016